Ethical issues are often not addressed in national clinical practice guidelines for dementia

Twelve national dementia clinical practice guidelines included only half of 31 ethical issues the authors had identified as important in patient care, finds a study by Daniel Strech, of Hannover Medical School, Hannover, Germany, and colleagues, published in this week's issue of PLOS Medicine.

The authors identified current national clinical practice guidelines for dementia care published in English or German. They had previously systematically reviewed ethical issues in dementia care and they used thematic text analysis to assess whether and how the ethical issues were addressed in the guidelines. In the 12 national practice guidelines identified, an average of 49.5% of the 31 ethical issues were addressed (range, 22% to 77%). National guidelines differed substantially with respect to which ethical issues were represented, whether ethical recommendations were included, whether justifications or citations were provided to support recommendations, and to what extent the ethical issues were explained.

The clinical practice guidelines were published by a central governmental institution in 6 countries (Australia, France, Malaysia, New Zealand, Singapore, United Kingdom), by a medical association in 4 countries (Canada, Germany, Scotland, United States of America), one by a statutory health insurance body (Austria), and by an expert panel in one country (Switzerland). The authors state, "All guidelines explicitly acknowledged the involvement of experts from different specialties (most often from psychiatry, neurology, gerontology, and family medicine)."

Four (13%) ethical issues were not addressed in at least 11 out of 12 CPGs: "Adequate consideration of existing advance directives in medical decision making.", "Usage of GPS and other monitoring techniques ", "Covert medication" and "Dealing with suicidality."

The authors conclude, "Ethical issues and how to deal with them are important for guidelines to address, for the medical profession to understand how to approach care of patients with dementia, and for patients, their relatives, and the general public, all of whom might seek information and advice in national guidelines."

Furthermore, although clinical practice guidelines are "meant to improve standards of clinical competence and professionalism by referring explicitly to evidence-based information on benefits and harms", the authors state that clinical practice guideline development manuals worldwide fail to address how to include disease-specific ethical issues.

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